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SET GOALS. BE HEALTHY. Nutrition Coaching FLOYD COUNTY BRANCH CONGRATULATIONS You have taken an important step toward a healthier life. The following Nutrition Coaching Packet includes all you need to begin your program. Please indicate which Nutrition Coaching Package you have chosen: 1 Session Package: $40 3 Session Package: $100 6 Session Package: $190 Please complete the Health Questionnaire, the Food, Liquid and Activity Form (directions below) and sign the Waiver and Release. After completing your packet, return it to the front desk along with your payment. All Nutrition Coaching sessions are non-refundable. Sessions that you purchase must be used within 6 months of purchase date. Food, Liquid and Activity Form Directions Fill out for three consecutive days using one log per day. Try to make them as “normal” as possible so that Tarah gets a true idea of your habits. Be specific and detailed. (i.e. turkey sandwich is not detailed enough, write 3 oz. turkey, 2 slices of white bread, slice of tomato, 2 tbsp. honey mustard, etc.). Write down everything that goes into your mouth, no matter how minute you think it is, even liquids. Once Packet and Payment are Received After the packet and payment are received, you will be contacted by Tarah Chieffi, our nutrition educator to arrange a time for your first appointment. Please allow approximately five days for contact so she has time to receive the packet and review it. Your nutrition consultation sessions will be scheduled between Tarah and you. It is the member’s responsibility to contact Tarah at least 24 hours in advance to reschedule any session. Failure to adequately contact the nutrition educator will count as a paid session. Health Questionnaire Nutrition Coaching FLOYD COUNTY BRANCH General Information Client name: ____________________________________________ Home phone: ___________________________________________ Date of birth: __________________________________________ Cell phone: ______________________________________________ Gender: __________________________________________________ Address: _________________________________________________ Referred by: ____________________________________________ Email: ____________________________________________________ Health History Height: ______________________________________________________________________________________________________________________ Current weight/desired weight: ________________________________________________________________________________________ Primary care physician? _________________________________________________________________________________________________ Contact information? __________________________________________________________________________________________ When did you have your last complete physical? _________________________________________________________________ Are you currently seeing other health practitioners? Yes / No Names and specialties? _______________________________________________________________________________________ Have you had any serious accidents or surgeries? List them here. ____________________________________________ ________________________________________________________________________________________________________________________________ How would you describe your health up until this time? _________________________________________________________ Do you have any chronic health conditions? List them here. ___________________________________________________ ________________________________________________________________________________________________________________________________ Do you miss much work? Yes / No If yes, what are the reasons? ________________________________________________________________________________ How have you dealt with your health issues (doctor, medication, alternative care, etc.)? ________________________________________________________________________________________________________________________________ How often do you get sick? ____________________________________________________________________________________________ Does it take you long to recover? __________________________________________________________________________ Present Health Concern Describe your reasons for seeking nutrition consultation at this time: ______________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ What are you primary health concerns? _____________________________________________________________________________ What are your symptoms? ______________________________________________________________________________________________ When did these begin? __________________________________________________________________________________________________ Have you been diagnosed by a doctor? ______________________________________________________________________________ Do you have lab test results? Yes / No Was there anything different or particular about your life at the time of onset? __________________________ ________________________________________________________________________________________________________________________________ How did you address these concerns before now? _______________________________________________________________ ________________________________________________________________________________________________________________________________ Are you aware of anything that makes your symptoms better or worse? ___________________________________ ________________________________________________________________________________________________________________________________ Are there any times of the day when you feel better or worse? _______________________________________________ Do any family members have similar health concerns now or in the past? __________________________________ Do any medical conditions run in your family? _____________________________________________________________________ What prescription/over-the-counter medications are you currently or regularly taking? ________________ ________________________________________________________________________________________________________________________________ How long have you been taking them? _____________________________________________________________________ What is the reason for using them? ________________________________________________________________________ Have you seen any positive or negative effects? ________________________________________________________ Who is overseeing the use of these medications? _______________________________________________________ What vitamin, mineral, herbal or other supplements do you regularly take? ________________________________ ________________________________________________________________________________________________________________________________ How long have you been taking them? _____________________________________________________________________ What is the reason for using them? ________________________________________________________________________ ______________________________________________________________________________________________________________________ Have you seen any positive or negative effects? ________________________________________________________ Who is overseeing the use of these supplements? ______________________________________________________ Do you have gastrointestinal/digestive problems? ________________________________________________________________ How often do you have bowel movements? ________________________________________________________________________ Do you experience constipation… diarrhea… other? ____________________________________________________ Women: Do you have menstrual periods? Yes / No Are they painful? _______________________________________________________________________________________________ Do you get PMS? _______________________________________________________________________________________________ Number of days between periods? __________________________________________________________________________ Length of period? _______________________________________________________________________________________________ Do you use contraceptives? Yes / No What type? _______________________________________________________________________________________________________ Length of use? __________________________________________________________________________________________________ Are you taking hormone replacement therapy? Yes / No What type? _______________________________________________________________________________________________________ Length of use? __________________________________________________________________________________________________ Do you get up during the night to urinate? Yes / No If so, how often? _______________________________________________________________________________________________ Men: Do you get up during the night to urinate? Yes / No If so, how often? _______________________________________________________________________________________________ Are you experiencing erectile dysfunction? Yes / No Lifestyle History What is your living situation (alone, with friend, roommate, relative, partner, spouse, # of children, pets, etc.)? _________________________________________________________________________________________________________________ What types of movement, physical activities or exercise do you engage in? _______________________________ ________________________________________________________________________________________________________________________________ Frequency and intensity? _____________________________________________________________________________________ How much sleep do you get on an average night? ________________________________________________________________ Describe the quality of sleep: ________________________________________________________________________________ How is your energy level: poor, fair or good? ______________________________________________________________________ Does your energy fluctuate during the day? ______________________________________________________________ Do you have quality time with family and friends? ________________________________________________________________ What do you do to relax? _______________________________________________________________________________________________ How much time do you devote to rest, self care, personal time, recreation and/or creativity? _________ ________________________________________________________________________________________________________________________________ What do you do for a living? ___________________________________________________________________________________________ Number of work hours per week? ___________________________________________________________________________ Do you like your current job? ________________________________________________________________________________ Have you worked or lived in an environment where you are exposed to pesticides, chemicals, heavy metals or other pollutants? ____________________________________________________________ Is there much stress in your life? _____________________________________________________________________________________ What causes you the most stress? _________________________________________________________________________ How do you cope with the stress? __________________________________________________________________________ Do you smoke, drink alcohol or use recreational drugs? Yes / No Types and frequency? _________________________________________________________________________________________ Are you happy in your life at this time? _____________________________________________________________________________ Do you have adequate support? ______________________________________________________________________________________ Diet History Describe a current typical day’s diet: ________________________________________________________________________________ ________________________________________________________________________________________________________________________________ Do you enjoy the food you eat? _______________________________________________________________________________________ Do you have regular meal times? _____________________________________________________________________________________ Where do you usually eat meals? _____________________________________________________________________________________ Do you eat slowly and chew your food well? _______________________________________________________________________ Has your diet changed in regards to your current health concerns? Yes / No If yes, how has it changed? __________________________________________________________________________________ If yes, what was your diet like at the time your health concerns started? _________________________ ______________________________________________________________________________ Have you experienced periods of eating junk foods, restrictive dieting, or binge eating? Yes / No When, how long? _______________________________________________________________________________________________ How many times do you eat out each week? _______________________________________________________________________ How many times do you eat “fast foods” each week? ____________________________________________________________ Do you reach for certain foods to cope with stress or emotions? Yes / No Which ones? _____________________________________________________________________________________________________ What are your comfort foods? ________________________________________________________________________________________ Do you use artificial sweeteners? Yes / No If so, which ones and how often? ___________________________________________________________________________ What is your relationship with sugar (frequency and amount)? ________________________________________________ Describe your typical diet and eating habits while you were growing up: ____________________________________ ________________________________________________________________________________________________________________________________ Do you have foods sensitivities, allergies or restrictions? ______________________________________________________ Are you on a special diet? ______________________________________________________________________________________________ How many glasses of water do you drink during a typical day? ________________________________________________ Describe your appetite in the morning, afternoon and night. ___________________________________________________ ________________________________________________________________________________________________________________________________ How do you feel if you skip a meal or eat sugary foods? _______________________________________________________ ________________________________________________________________________________________________________________________________ Do you crave any of the following foods: Sweets? Yes / No Chocolate? Yes / No Breads? Yes / No Fatty foods? Yes / No Salty foods? Yes / No Dairy? Yes / No Meat? Yes / No Other? ____________________________________________________________________________________________________________ How is your digestion? __________________________________________________________________________________________________ After eating, do you feel well nourished and energized or tired and sluggish? _____________________________ _____________________________________________________________________________________ Health Support What is your desired health outcome? _______________________________________________________________________________ ________________________________________________________________________________________________________________________________ Can you imagine being completely healthy? ________________________________________________________________________ How would your life be different? ____________________________________________________________________________________ Would you be willing to make changes in your current diet or lifestyle if you believed it would be beneficial to your health? ______________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ Do you have friends or family who will be supportive of you during your healing process? _____________ ________________________________________________________________________________________________________________________________ FOOD, LIQUID AND ACTIVITY FORM Nutrition Coaching FLOYD COUNTY BRANCH Name: ___________________________________________________________________________________________________ Check all that apply: Typical Day Food and Liquid Consumed Work Day Day off Portion Size Breakfast Lunch Dinner Snacks *1 (not hungry or not satisfied) – 5 (very hungry or completely satisfied) Time Date: ______________________________________________________________________________ Unusual Day Hunger Level Before *Scale: 1-5 Satisfaction After *Scale: 1-5 Supplements/ Dosage Physical Activity Type and Duration FOOD, LIQUID AND ACTIVITY FORM Nutrition Coaching FLOYD COUNTY BRANCH Name: ___________________________________________________________________________________________________ Check all that apply: Typical Day Food and Liquid Consumed Work Day Day off Portion Size Breakfast Lunch Dinner Snacks *1 (not hungry or not satisfied) – 5 (very hungry or completely satisfied) Time Date: ______________________________________________________________________________ Unusual Day Hunger Level Before *Scale: 1-5 Satisfaction After *Scale: 1-5 Supplements/ Dosage Physical Activity Type and Duration FOOD, LIQUID AND ACTIVITY FORM Nutrition Coaching FLOYD COUNTY BRANCH Name: ___________________________________________________________________________________________________ Check all that apply: Typical Day Food and Liquid Consumed Work Day Day off Portion Size Breakfast Lunch Dinner Snacks *1 (not hungry or not satisfied) – 5 (very hungry or completely satisfied) Time Date: ______________________________________________________________________________ Unusual Day Hunger Level Before *Scale: 1-5 Satisfaction After *Scale: 1-5 Supplements/ Dosage Physical Activity Type and Duration Waiver and Release Nutrition Coaching FLOYD COUNTY BRANCH Tarah Chieffi provides nutrition information and does not diagnose or treat disease. You should consult a Physician for diagnosis and before undergoing any dietary or food supplement changes. Any recommendations you follow for changes in diet, including but not limited to the use of food supplements, are entirely your responsibility. In consideration of my participation in Nutrition Coaching, I hereby accept all risk to my health and of my injury or death that may result from such participation and I hereby release Tarah Chieffi and the YMCA of Greater Louisville from any liability to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all illness or injury to my person, including my death, that may result from or occur during my participation in Nutrition Coaching, whether caused by negligence of Tarah Chieffi or otherwise. I further agree to indemnify and hold harmless Tarah Chieffi and the YMCA of Greater Louisville from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in the described Nutrition Coaching session. All of Tarah Chieffi’s communications, including her Nutrition Coaching and her website, make it clear that her recommendations and writings offer no guaranteed cure for disease. I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR MY INJURY OR DEATH OR DAMAGE TO MY PROPERTY THAT OCCURS WHILE PARTICIPATING IN NUTRITION COACHING AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY NEGLIGENT OR INTENTIONAL ACT OR OMISSION. Client Name (printed): ______________________________________________ Date: ______________________________________ Client Signature: _____________________________________________________